Botulinum toxin type A and hyaluronic acid fillers are commonly used to correct rhytides in the brow and forehead area.^14,15 The neurotoxin botulinum toxin type A has been available for more than 20 years^16,17 and is approved for the temporary improvement of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity.¹⁸ Additionally, botulinum toxin type A has been used to diminish the appearance of forehead lines and crow’s feet as well as to elevate the eyebrows by changing the dynamic interrelationship of the muscles around the brow.¹⁹ Although some authors recommend avoiding the injection of botulinum toxin type A below the orbital rim,²⁰ I have been using it at the level of superior orbital rim near the tail of the brow with great success. Also, as others have noted, botulinum toxin type A can be used in several other facial areas.^21-24 For example, in my own clinical practice, I have been applying it in platysmal neck bands to help reduce their activity, as well as for the correction of perioral rhytides. I also use it in patients with Bell palsy and facial paralysis to control synkinesis and symmetrize the facial appearance.

Several hyaluronic acid derivatives are approved by the FDA for correction of moderate to severe facial wrinkles, such as nasolabial folds.^25-29 In addition, these agents have been used to increase fullness in the brow area³⁰ and to correct tear trough deformity.^31-33 Cross-linking between carboxyl and N-acetyl groups enhances the viscosity of the naturally occurring hyaluronic acid, thereby increasing its stiffness and changing its water-retention properties.³⁰ Thus, after injection, some hyaluronic acid derivatives may continue to swell as they absorb water from surrounding tissues. However, these products are resorbed slowly over a period of 4 to 8 months. In describing their experience of administering 244 hyaluronic acid gel injections in 155 patients with periorbital hollows, Goldberg and Fiaschetti³¹ noted that 89% of the patients were satisfied with the cosmetic improvement. However, hyaluronidase injections were necessary at follow-up visits to break down the hyaluronic acid which was thought to be the cause of contour irregularities in 15% of patients. Kane^32,33 reported the use of hyaluronic acid gel injections to treat tear trough deformity in a smaller patient population. Of 24 patients treated, only 2 were dissatisfied with the results and no patient required the use of hyaluronidase injections to correct irregularities. The injection technique described by Kane is designed to minimize the appearance of lumps or ridges when hyaluronic acid gel is used in this delicate skin area.³³ Following application of a topical anesthetic to the lower eyelids, the manufacturer-supplied needle is used to inject the dermatologic agent. The full length of the needle is inserted below the surface of the skin and minuscule threads of hyaluronic acid gel are injected below the orbicularis oculi muscle. In many individuals a minimal amount may also be injected in the plane between the dermis and the orbicularis oculi muscle in a crosshatched pattern. It is important to gradually decrease the amount of filler injected in the border areas in order to keep a smooth contour. Most patients require 0.3 to 0.5 mL of filler per eyelid, but more may be needed for deep depressions. Patients should be instructed to apply cold compresses to the area and keep their head elevated for 2 days following the procedure.^32,33 In my own practice, I generally inject hyaluronic acid products deep into the orbicularis oculi to avoid the Tyndall effect (bluish hue under the skin). I then use subcutaneous injections to even out fine irregularities.

Products used for volume restoration in this area of the face include injectable PLLA,^34,35 and calcium hydroxylapatite.^36,37 Hyaluronic acids and porcine collagen may also be used, depending on the goals of the patient. Injectable PLLA is a polymeric device that contains microparticles of PLLA, a biodegradable, biocompatible synthetic polymer from the α-hydroxy acid family. Injectable PLLA is approved by the FDA for correction of the signs of facial fat loss (lipoatrophy) in patients with the human immunodeficiency virus (HIV).³⁸ Injectable PLLA is also approved for facial cosmetic use in Europe, Canada, and Australia.³⁴ Currently, an application for volume restoration and/or correction of facial wrinkles and folds such as nasolabial lines or folds is pending approval from the FDA.

In an open-label clinical study, patients with HIV-associated lipoatrophy experienced a 65% increase in skin thickness after undergoing a series of treatment sessions with injectable PLLA. This increase was maintained throughout a 12-month follow-up period.³⁹ The effects of injectable PLLA have a gradual onset and have been reported to last up to about 2 years.³⁴ Many of my patients have experienced an increase for up to 3 years. It is important to note that the safety and effectiveness of treatment with injectable PLLA in the periorbital area have not been established.³⁸ Therefore, only highly experienced practitioners should use injectable PLLA in this area.⁴⁰

Calcium hydroxylapatite, consisting of 25 to 45 µm particles suspended in a gel,⁴¹ is indicated for the correction of moderate to severe facial wrinkles, such as nasolabial folds, and the signs of facial fat loss (lipoatrophy) in people with HIV.⁴² Because of the gel’s viscosity, care must be used when injecting this device in facial sites.⁴³ Calcium hydroxylapatite is most commonly used to correct depressions in nasolabial folds, cheeks, deep glabellar creases, oral commissure, horizontal mental crease, and acne scars. It is a versatile product⁴⁴ that is also applied in the malar and submalar regions as well as the prejowl sulcus.³⁶ It should be injected into the immediate deep subdermal layer; more superficial placement increases the risk of visibility and nodule formation.³⁶

In an open-label study,⁴⁴ calcium hydroxylapatite was associated with very good or excellent results in 90% of the 113 study participants; in this subgroup, 15 participants received injections into the cheeks, 86—into the nasolabial folds, and 26—into perioral lines. Adverse events were mild, resolved within 1 month, and were reported by a small number (7) of study participants.⁴⁴ In a separate study, 609 participants received a total of 1348 injections of calcium hydroxylapatite⁴⁵; 112 participants completed satisfaction surveys at 12 to 14 months and 69% of them reported continuing satisfaction.⁴⁵ Postinjection lip nodules that generally resolved with steroid injections or repeated massage occurred in 42 participants who had injections into the lip mucosa or radial lip lines.⁴⁵ Because it is liable to form lip nodules, calcium hydroxylapatite should not be used in the lip area. Furthermore, only a skilled practitioner should perform injections of calcium hydroxylapatite in the lower eyelid and nose. The use of injectables in the nose should only be done to correct contour irregularities in patients who do not desire to have rhinoplasty performed for the foreseeable future. In my practice, I utilize hyaluronic acids due to their reversibility and short duration only in a very small group of individuals who have minor contour irregularities.

Noninvasive, nonsurgical skin rejuvenation techniques and treatments, such as fractional laser resurfacing and medical grade topical skin-care agents, can be used in combination with the aesthetic procedures described above to enhance outcomes. The 1320-nm neodymium: yttrium-aluminum-garnet (Nd:YAG) laser (CoolTouch, New Star Lasers, Roseville, CA) emits infrared light that promotes dermal collagen synthesis. However, concern about possible distortion of the injectable collagen implants from the heat of laser treatments has limited their concomitant usage.⁴⁶ Goldman and colleagues determined that Nd:YAG laser treatment administered immediately after hyaluronic acid gel implantation did not result in a reduction of the clinical effect of either device; they also found that concomitant therapy was not associated with an increase in adverse event occurrence. Similarly, injection of botulinum toxin type A into the periorbital area either before or after erbium:YAG laser (Focus Medical, CT) resurfacing enhanced the improvement of periorbital rhytides as well as periorbital skin texture and pigmentation.⁴⁷ To further optimize the results of the selected procedure, skin-care regimens should be discussed with patients undergoing surgical or nonsurgical facial volume replacement procedures so that improvements can be maintained. Medical grade topical skin-care agents (“cosmeceuticals”) containing ingredients such as vitamin C, α-hydroxy acids, retinoic acid derivatives, and skin growth factors may have beneficial effects on skin and slow the appearance of further signs of aging.⁴⁸